Cambridge University Press 978-1-108-45028-7 — The Emergency Medicine Trauma Handbook Edited by Alex Koyfman , Brit Long Excerpt More Information Chapter General Approach to 1 Traumatic Injuries Ryan O’Halloran and Kaushal Shah Introduction Trauma is the fourth leading cause of death overall in the United States and the number one cause of death for ages 1 to 44 – second only to heart disease and cancer in those older than 45 (CDC).1 As the disease burden from infectious diseases declines and secondary preven- tion of chronic conditions improves, the relative importance of the practice of trauma care becomes even more apparent. Though safety engineering has improved across many indus- tries (one need only consider examples such as crosswalk and bike lane planning, football helmet technology, and motor vehicle computerized improvements), trauma remains a significant threat to life and limb in emergency medicine. The Trauma Team The American College of Surgeons, the governing body for credentialing trauma centers, has provided guidelines for optimal resources necessary for a coordinated response to a critically injured trauma patient. Box 1.1 demonstrates the players suggested for an optimal response. While response teams may vary, several principles are key to the functioning of a good, interdisciplinary team. These include clearly establishing roles for members of the team, following policy and protocols established in advance, briefing prior to the arrival of the patient, and debriefing after the event, whether immediately after the event or through quality case review. Successful team dynamics include the ability to be fluid, adaptable, and communicative. Team leaders must focus on the big picture: overall physiologic status of the patient, triage of resources available in the trauma room, assigning tasks to individuals or groups of Box 1.1 Human Resource Response to Trauma Activations Emergency Physician Emergency/Trauma Nurses Trauma Surgeon Anesthesiologist Radiology Tech (and radiologist) Blood Bank, Laboratory Support Staff Respiratory Therapist Social Worker Security 1 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-108-45028-7 — The Emergency Medicine Trauma Handbook Edited by Alex Koyfman , Brit Long Excerpt More Information 1. General Approach to Traumatic Injuries Table 1.1 Adapted in part from ALiEM article by Arlene Chung, an effective team debriefing checklist2 ✔ Set ground rules (purpose, safe environment) and time expectations (5–10 minutes) ✔ Present facts of the case (avoid excessive detail) Can you give us an overview about what happened from your viewpoint? ✔ Elicit thoughts What was your first thought or most prominent thought? ✔ Discuss reactions (emotions) How did that go? What were you feeling? ✔ Discuss the facts of the case, medicine, and What was the worst? What was the best? teamwork ✔ Teaching and learning What could have gone better? ✔ Re-entry and closure (validate emotions, highlight learning points) Box 1.2 Trauma Teams That Are Successful at Helping Patients Work Together Well Institutionally organized policy and plans for interdepartmental cooperation Designated team leader “Pre-briefing” prior to arrival of trauma patients Debriefing and/or quality clinical reviews, of trauma resuscitations Closed-loop, concise, out-loud communication Systematic, reproducible approach to every trauma patient Ability to be fluid, adaptable, and communicative individuals, and planning for the next series of actions for the patient and team. A systematic approach to the patient is important (discussed in Box 1.2), as is a systematic approach to directing the team. Critical actions, while they may be pre-designated to a member of the team by policy, must be verbalized and confirmed. Intravenous access, for example, is crucial for a sick trauma patient. Direct, closed-loop communication among team members is essential in trauma management. This call-and-response principle can be extrapolated to all critical tasks in the trauma room. Trauma team members are often exposed to high stress, highly emotional situations. Team debriefing is critical for emotional well-being, education, and resolution of deficien- cies, demonstrated in Table 1.1. It is ideal that a formal debriefing, even if only a few minutes, be completed after every trauma team activation. These meetings may be delayed based on the circumstances of the patient (e.g., going immediately to the operating room), but should be attempted as often as is practical, with as many of the team members as possible. Emergency Medical Services (EMS) The first step in the series of steps that can optimize outcome in trauma is accurate triage (with overtriage preferred over undertriage), rapid care that addresses immediate life 2 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-108-45028-7 — The Emergency Medicine Trauma Handbook Edited by Alex Koyfman , Brit Long Excerpt More Information Ryan O’Halloran and Kaushal Shah Measure vital signs and level of consciousness Step One Glasgow Coma Scale ≤13 Systolic Blood Pressure (mmHg) <90mmHg Respiratory rate <10 or >29 breaths per minute* (<20 in infant aged <1 year), or need for ventilatory support Transport to a trauma No center.* Steps One and Two attempt to identify the most seriously injured Assess anatomy Ye s patients. These patients of injury should be transported preferentially to the highest level of care within § Step Two All penetrating injuries to head, neck, torso and extremities proximal to elbow the defined trauma system. or knee Chest wall instability or deformity (e.g, flait chest) Two or more proximal long-bone fractures Crushed, degloved, mangled, or pulseless extremity Amputation proximal to wrist or ankle Pelvic fractures Open or depressed skull fracture Paralysis No Assess mechanism of injury and evidence of high-energy impact Step Three§ Falls Adults: >20 feet (one story is equal to 10 feet) Children: >10 feet or two or three times the height of the child Transport to a trauma High-risk auto crash center, which, depending Intrusion,** including roof: >12 inches occupant site;>18 inches any site upon the defined trauma Ejection (partial or complete) from automobile Ye s sysytem, need not be the Death in same passenger compartment highest level trauma Vehicle telemetry data consistent with a high risk of injury center.** Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact44 Motorcycle crash >20 mph No Assess special patient or system considerations Step Four Older adults44 Risk of injury/death increases after age 55 years SBP <110 might represent shock after age 65 years Transport to a trauma Low impact mechanisms (e.g. ground level falls) might result in severe injury center or hospital capable Children of timely and thorough Should be triaged preferentially to pediatric capable trauma centers evaluation and initial Anticoagulants and bleeding disorders Ye s management of potentially Patients with head injury are at high risk for rapid deterioration Burns serious injuries. Consider Without other trauma mechanism: triage to burn facility*** consulation with medical With trauma mechanism: triage to trauma center*** control. Pregnancy >20 weeks EMS provider judgment No Transport according to protocol*** When in doubt, transport to a trauma center Figure 1.1 CDC guidelines for field triage of injured victims3 (courtesy of the Centers for Disease Control, USA) threats, and prompt transport to the appropriate level trauma center (see CDC guidelines chart, Figure 1.1) by EMS personnel.3 EMS professionals perform an abridged version of the hospital team’s primary and secondary surveys. Many EMS systems rely on basic-level Emergency Medical Technicians (EMTs) to respond to calls for traumatic injuries. Modern EMT-staffed Basic Life Support ambulances carry equipment more advanced than simple standard first aid, such as tourniquets and hemostatic dressings for severe hemorrhage, and supraglottic airway devices. Paramedics, the highest trained pre-hospital providers, are capable of intubation, 3 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-108-45028-7 — The Emergency Medicine Trauma Handbook Edited by Alex Koyfman , Brit Long Excerpt More Information 1. General Approach to Traumatic Injuries needle decompression, and IV and IO access. Regardless of the level of skill, or equipment available, rapid transport to the appropriate hospital is key to survival. Some controversial studies have suggested that police officers ought not to wait for EMS to transport victims – inferring that speed, rather than care provided in the interim of transport, is most – important.4 9 EMS notification to the receiving hospital allows for the trauma team to assemble, prepare equipment, and “pre-brief,” as described earlier, in anticipation of their arrival. In some urban systems this may be a quick “heads-up” that the ambulance is around the corner. In rural settings, the patient may be coming by air or ground from hours away. In extreme circumstances, notification may provide time for the calling-in backup personnel (such as in multiple or mass casualty incidents) or setup of decontamination equipment. Upon entering the trauma room, the team leader ought to obtain a brief history from EMS about the mechanism of injury, vital signs, interventions started, and IV or IO access already obtained. This information, while easily